Path of Moderation

Recently, a Member of Parliament who is also a doctor said that politicisation is bad for healthcare. Once politicians get heavily involved and health policy gets heavily politicised, healthcare delivery generally suffers.

That is the commonly held view. This hobbit also agrees with this observation to a large extent. BUT real life is not so simple or absolute. Or as Obiwan Kenobi said to Anakin Skywalker “Only a Sith speaks in absolutes”.

The idea of Singapore as an Administrative State (as opposed to a political or politicised one) was first made popular as far back as 1975 when Prof Chan Heng Chee wrote a paper titled “Politics in an Administration State: Where has the Politics Gone?”

Singapore was largely an administrative state until 2011.  But even as an administrative state, (the period before 2011), things got a bit edgy and rough for healthcare.

There are fundamental differences between administrators and politicians. And these differences lead to problems. For one, politicians in a democracy have to face the ballot box and the polity. Civil service administrators don’t have to.

So let’s look back at some of the experiences that a largely de-politicised and an administrative state have brought us.

Problem #1: Play It Safe

The first thing about being administrative is that it doesn’t engender innovation and risk-taking. Have you heard of a term such as “administrative innovation” or an “innovative administrator”? It’s almost oxymoron. We have heard of stuff like technological innovation, educational innovation, clinical innovation and even financial innovation, but administrative innovation? It is as rare as hen’s teeth.

Because we had an overwhelmingly administrative climate, people decided to copy lock-stock and barrel the ACGME system and hence now we have the ACGME-I system that is neither recognized even in JB nor Batam. There is safety in copying. Administrators are not praised or rewarded for innovation.

Problem #2: Dogma beats Real Experience

Remember the now-defunct SMA Guideline of Fees (GOF)? If you polled doctors in private practice and the man-in-the-street today, this Hobbit will bet that at least 90% of those polled will disagree that withdrawal of the GOF led to lower bills or a slower rise in bill size for patients. This was exactly what SMA said when it was reluctantly forced to withdraw the GOF. But we are still stuck in the dogma that guidelines of fees are bad for the consumer/patient and that there must be market competition. Some things just don’t conform to the dogma of market fundamentalism and competition. Healthcare is one. Other examples? Just look at our public transport and the big money we are paying to watch football on cable in Singapore.

All this was achieved when we were an administrative state with little politicisation. Dogma wins over our real life experience in healthcare, public transport and even the simple pleasure of watching football.

That’s not to say that competition is always bad. In most cases, it’s good. But it cannot become a dogma or even a religion and applied without question in all instances. Holding on to a dogma blinds us from achieving intellectual honesty.

Problem #3: The Secret Mojo of Complexity

Administrators want to be known as the clever people. There’s nothing wrong in that per se. Who doesn’t want to be known as smart? That’s how the term “policy wonk” came about. It underscores the importance and desirability of creating policies that reflect the intelligence and knowledge of the administrators. That’s where the problem starts because complexity often becomes a proxy for smartness.

Have you noticed for example the complexities of public healthcare funding and hospital charging? One experienced hospital administrator told this Hobbit half-seriously that no one really knows all the funding rules and mechanisms that have been implemented in our public institutions. There is service funding, capital expenditure funding, research funding, block funding, training funding, productivity funding, innovation funding, transition funding, research grants, emergency preparedness funding along with stuff like Medisave, Medishield, Medifund, Eldershield, disability grants and subsidies, funding for non-standard drugs and implants, blue and orange CHAS… the list goes on….And of course now we have the newer stuff like Pioneer Generation Package and Medishield Life as well.

This Hobbit speculates that if real politicians or political minds got into the act of designing the funding and paying system for healthcare, things would have been a lot simpler. Because politicians see the need to communicate and effective communication is often simple communication. Civil Servants, especially the elite and brainier ones – the policy wonks – love complexity. Policy complexity is the secret mojo of the administrative state…. But please pity the hospital and polyclinic counter staff who has to deal with all this complexity and an increasingly demanding and impatient customer/patient.

Enough about politicisation. This Hobbit agrees that we should guard against over-politicisation of healthcare. But a little politicisation of healthcare need not be a bad thing. Certainly, it can guard against some of the problems we have experienced as an almost purely administrative state.

But there are two other “-tions” we have to also guard against in healthcare.

Legalisation

One area we need to really guard against is over-legalisation. Again, the SMC disciplinary has been increasingly legalised to the point it is now been described as a “pseudo-criminal” process. There can be three groups of lawyers or legally trained people in a SMC Disciplinary Tribunal (DT) proceeding. (one group for the defending doctor, one group for prosecution and one group advising the SMC DT as legal assessor or one SMC DT member may be legally trained in which case there is no legal assessor)

This over-legalisation of medicine has led to much higher practice insurance premiums and more and more defensive medicine that must largely be borne in the end by the patient and creates a lot more angst and anxiety suffered by doctors. Only the lawyers almost always benefit (provided they get paid, which of course, they would be).

Some legalisation is necessary, because we live in a country with a strong rule of law and we benefit from this. Having said that, must a SMC trial run like a full legal trial and in an adversarial manner? Some other professions actually have far less legalised and adversarial processes.

Commercialisation

The third “-tion” is commercialisation. Again, some commercialisation is necessary for the simple reason that healthcare workers need to eat, feed their kids and pay an arm and a leg to watch the 2014 World Cup. But the problem here is over-commercialisation.

One clear example is again that of the withdrawal of GOF. The market trumps ethics and professionalism. Another is that of the liberalisation of medical advertising. If you ask the leaders of the independent medical professional bodies (i.e. those who led AMS, CFPS or SMA) in Singapore 15 to 20 years ago, they did not support liberalising medical advertising. But the powers that were decided this was a good thing and look what we have now – rampant medical advertising and pseudo-advertising. Some of the stuff are downright embarrassing.

Confucius advocated a “Path of Moderation”. When we have too much or too little of something, it usually is a bad thing. Zero-politicisation of healthcare may not be a good thing, just as over-politicisation is usually a bad thing. But along with over-politicisation, we also have to guard against and fight over-commercialisation and over-legalisation of healthcare.

Politicisation, Commercialisation and Legalisation – We can’t live without them in healthcare, but let’s not have too much of them either. We need moderation.

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